Factors associated with status and self-perceived mental health changes in the face of the COVID-19 pandemic in Brazil

The SARS-CoV-2-triggered Public Health Emergency of International Importance has significantly contributed to emotional and mental health issues. The aim of this study was to identify factors associated with self-perceived mental health changes while facing the COVID-19 pandemic in Brazil. This was a cross-sectional, descriptive, and analytical study that collected data via a web survey using a validated instrument. The study included individuals over 18 years old residing in the 26 federal units and the Federal District from August 2020 to November 2022. The sample was recruited using the snowball technique. Two logistic regression analyses were conducted to identify factors associated with the outcomes of interest. The first analysis considered individuals who rated their mental health condition as poor as the dependent variable, while the second analysis considered individuals who reported changes in their mental health during the pandemic as the dependent variable. The study found that individuals with complete college education and those using tranquilizers or antidepressants were more likely to perceive their mental health as poor (1.97 and 2.04 times higher likelihood, respectively). Increased consumption of ultra-processed foods during the pandemic was associated with a 2.49 higher likelihood of reporting mental health changes. Participants also reported more difficulty sleeping. The negative self-perception of mental health varied across Brazil’s regions and changed over time, with different patterns observed before and after the vaccination period. In 2022, most regions of Brazil classified their mental health as "poor." The study highlights the impact of the COVID-19 pandemic on mental health, with increased prevalence of mental disorders and emotional problems among the population. The results highlight the presence of mental disorders and increased reporting of emotional problems among the population due to the impact of the COVID-19 pandemic.


Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported Pág. 2paragraph 1. The COVID-19 pandemic had immeasurable impacts on the lives and health of people around the world. Since 2020, the Pan American Health Organization (PAHO) has warned about the increase in mental suffering caused by the emergence of the new coronavirus. This is due to the strategies used for its The study population was made up of people who declared that they were Brazilians or foreign migrants who understood the language spoken in Brazil (Brazilian Portuguese) and had lived in Brazil for at least six months, 18 years of age or older, and who were willing to participate in the survey-having internet access available.
As for the sampling design, the study was based on a convenience sampling, using the snowball technique, which is characterized by the non-adoption of error margin calculations, since it is a non-probabilistic method. Therefore, we used the calculation for finite populations , arriving at a minimum sample size of 1,428 participants.
Participants 6 (a) Give the eligibility criteria, and the sources and methods of selection of participants Pág. 4paragraph 3 and 4. The study population was made up of people who declared that they were Brazilians or foreign migrants who understood the language spoken in Brazil (Brazilian Portuguese) and had lived in Brazil for at least six months, 18 years of age or older, and who were willing to participate in the survey-having internet access available.
As for the sampling design, the study was based on a convenience sampling, using the snowball technique, which is characterized by the non-adoption of error margin calculations, since it is a non-probabilistic method. Therefore, we used the calculation for finite populations [12], arriving at a minimum sample size of 1,428 participants. Exploratory analysis was conducted for collinearity among the independent variables using the Variance Inflation Factor (VIF), and those with values greater than 10 were removed from statistical modeling. The modeling was performed using the backward stepwise selection method, in which one starts with a complete model (with all variables) and then removes the variables one by one and verifies the model's behavior. The best model considered was the one with the lowest Akaike Information Criterion (AIC) value.
It is also worth mentioning that for the final model, the Odds Ratio (OR) with their respective 95% Confidence Intervals (95%CI) were calculated.

Bias 9
Describe any efforts to address potential sources of bias Pág. 5paragraph 5 and 6. Exploratory analysis was conducted for collinearity among the independent variables using the Variance Inflation Factor (VIF), and those with values greater than 10 were removed from statistical modeling. The modeling was performed using the backward stepwise selection method, in which one starts with a complete model The validation analyses and tests were performed using RStudio software.
Study size 10 Explain how the study size was arrived at Pág. 5paragraph 1. Participants were invited to answer the questionnaire by accessing the link which was widely disseminated through the websites of the institutions participating in the research using e-mail, WhatsApp®, social networks (Facebook®, Instagram®, Twitter®) or blogs, in addition, people were invited from the network of contacts of the researchers involved. In addition, the participants were instructed to recruit other people from their social circle to participate in the survey, in order to obtain the expected sample.

Quantitative variables 11
Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why Pág. 5paragraph 2 and 3. After consistent analysis of the database, exploratory analyses were performed to characterize the profile of the people who answered the questionnaire.
To identify factors associated with the outcomes of interest, binary logistic regression was used based on the variables present on the "Social Thermometer" instrument (Questionnaire), which were dichotomized. In Table 2, it was possible to identify the factors associated with self-reported mental health change, and emotional change. It was found that people aged 18 to 39 years were less likely [OR: 0.37; 95%CI: 0.24 -0.56] to consider their mental health status poorly compared to other age groups, as they were people who reported not feeling agitated or sad as a result of the isolation measures (OR: 0.33; 95%CI: 0.14 -0.68). Regarding risk factors, it was identified that people with complete higher education (OR: 1.97; 95%CI: 1.21 -3.22) and people who reported using tranquilizers or antidepressants to cope with the current situation (OR: 2.04; 95%CI: 1.46 -2.85) were more likely to consider their mental health status poorly.
Pág. 11paragraph 1 and 2. To validate the model presented in Table 3, it was verified that the accuracy capacity of the model through the area under the ROC curve presented a value of 0.78, besides the Hosmer-Lemeshow test (p=0.52), likelihood ratio (p=<0.01), CoxSnell (0.12), Nagelkerke (0.24) and McFadden (0.17).
In Table 3, it was possible to identify four protective and one risk variable. We identified that individuals who had elementary school (OR: 0.24; 95%CI: 0.10 -0.58) or complete high school (OR: 0.30; 95%CI: 0.10 -0. 60) were less likely to report changes in their mental health status in the pandemic period compared to the pre-pandemic period. Also, people who did not start or increase their use of depressants and/or antidepressants pandemic in Brazil. We observed, more prevalence of situations such as being more agitated, anxious, sad, irritated, discouraged, crying more easily, and being more lonely.
Part of the subjects also reported more work overload and/or sleeping difficulties.
We also verified that among the resources to mitigate emotional problems and relief anxiety was to resort to self-medication and alcohol use. We identified that people with complete college education Pág. 14paragraph 3.When discussing the relationship of individuals with their residential environment in a physically distant situation in Brazil during the pandemic, one study signaled that physical distancing with prolonged stay inside the home was a source of stress for most participants in the country. The authors believe that such stress occurs mainly due to mobility restrictions, intensification of family interaction caused by the situation of being confined for several months.

Generalisability 21
Discuss the generalisability (external validity) of the study results Pág. 14paragraph 4. A longitudinal study that assessed the impact of lockdown on mental health during the first year of the COVID-19 pandemic in a general sample of the French population identified that such a health crisis strongly affected the occurrence and persistence of depression, anxiety, and post-traumatic stress disorder over time . The prevalence of depression symptoms among adults in the United States increased dramatically during the early months of the COVID-19 pandemic. A study that sought to understand the impact of the pandemic on people with a history of depression showed that this relationship increased the chances of negative effects of the pandemic on various aspects of life.

Other information
Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based not applicable *Give information separately for exposed and unexposed groups.
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.